胎心监护电脑分析系统在临床的应用

1背景 胎心电子监护作为一个重要的监测胎儿宫内安危的产前监护手段已在国内外普在用。大样本的对照研究 (10万以上病例 )显示，监护仪改善了重症围产儿预后，对降低围产儿发病率和死亡率起到了重要的作用。 1.1存在问题 由于胎儿生理和病理状态的多样性，导致了胎心监护图形的多样性，致使人工分析判断胎心监护有很大的局限性，如不能准确地预告新生儿的酸中毒等。对图形的解释和看法在不同的专家间存在着差异，如对变异减速的评判和解释，专家的观点就很不一致。还存在着变异减速和晚期减速的混淆及对正弱波的确切判断，同时对减速图形…     

阴道分泌物胎儿纤维连接蛋白与宫颈长度联合预测早产的多中心前瞻性研究

Objective To discuss the clinical value of fetal fibronectin (fFN) and cervical length in predicting preterm birth. Methods Totally, 511 pregnant women at 22-35 weeks of gestations were enrolled from Dec. 2006 to Dec. 2007 at 4 tertiary hospitals in Beijing, and all with either symptoms or high risk factors of preterm birth, but without preterm premature rupture of membrane or vaginal bleeding. Cervical fFN were determined and cervical length of each subjects were measured by ultrasound. The pregnancy outcomes were compared. Results The sensitivity, specificity and negative predictive value (NPV) of fFN in predicting preterm birth within 7 d were 77.4%, 69.4% and 97. 9%, respectively; and 70.5%, 70.0% and 96.2% for deliveries within 34 weeks. The above figures changed to 54.8%, 66.3%, 95.8% for deliveries within 7 d and 59.1%, 67.2%, 94.6% for those within 34 weeks, respectively, when cervical length ≤3 cm was applied to predict preterm birth. When fFN and cervical length were combined, the sensitivity, specificity and NPV were 51.6%, 87.1%, 96.5% for deliveries within 7 d, and 45.5%, 87.60/00, 94.5% for those within 34 weeks, respectively. Conclusions FFN has higher NPV and specificity than cervical length in predicting preterm birth within 7 d and 34 weeks, and the positive predictive value and specificity can be improved when combined with cervical length.     

胎儿脐动脉舒张末期血流缺失22例分析及妊娠结局

目的探讨妊娠期发生脐动脉舒张末期血流缺失（absentend—diastolic velocity,AEDV）的原因及与围生儿结局的关系。方法对2009年1月至2011年12月北京大学第一医院22例AEDV母儿的临床资料进行回顾性分析,并追踪妊娠结局。结果22例孕妇中,17例有合并症或并发症,5例无合并症或并发症。17例患者中,子痫前期13例,其中合并胎儿生长受限（FGR）5例,慢性高血压并发子痫前期1例,肾源性高血压并发子痫前期3例;单纯FGR者1例。慢性高血压合并妊娠1例;先天性心脏病（法洛四联症术后）1例;原发性抗磷脂综合征1例。双胎妊娠2例,其中选择性FGR1例,死胎1例;胎儿畸形3例,分别为尿道下裂、房间隔缺损及染色体异常（21-三体）,其中胎儿房间隔缺损孕妇合并重度子痫前期和FGR。结论以子痫前期为主的妊娠并发症是妊娠中晚期胎儿脐动脉血流缺失的主要病因。双胎妊娠中AEDV与选择性FGR有关。在无明确合并症或并发症的情况下出现AEDV应进一步寻找胎儿原因。     

阴道超声动态测量正常妊娠妇女的宫颈长度

目的 用阴道超声测量正常孕期宫颈长度变化并分析相关因素. 方法 回顾性分析595例妊娠37周后分娩的单胎正常孕妇于孕11～13+6周(Ⅰ期)、孕20～24周(Ⅱ期)、孕28～32周(Ⅲ期)及孕36周后(Ⅳ期)行阴道超声测量的宫颈长度,并记录各相关因素.统计学方法采用重复测量的方差分析、t检验和Spearman相关性分析. 结果 (1)Ⅰ、Ⅱ、Ⅲ及Ⅳ期的宫颈长度平均值分别为(38.85±3.11)mm、(38.92±4.10) mm、(36.43±4.69) mm和(30.63±6.11) mm.除Ⅰ和Ⅱ期外,其余任何2个时期比较,差异均有统计学意义(P均＜0.01).宫颈长度的变化比例中位数分别为Ⅱ-Ⅰ期0.00％、Ⅲ-Ⅰ期-5.36％、Ⅳ-Ⅰ期-20.00％.(2)年龄≥35岁的孕妇各孕期宫颈长度均值均大于年龄＜35岁的孕妇[Ⅰ期:(39.36±3.18) mm与(38.77±3.10) mm;Ⅱ期:(39.89±4.61) mm与(38.88±4.00) mm;Ⅲ期:(37.29±4.79)mm与(36.31±4.67) mm;Ⅳ期:(32.25±5.95) mm与(30.38±6.10) mm],但仅Ⅳ期差异有统计学意义(t=-2.56,P=0.01).经产妇各孕期宫颈长度的均值均大于初产妇[Ⅰ期:(38.95±2.59) mm与(38.76±3.14) mm;Ⅱ期:(39.54±3.62) mm与(38.82±4.11) mm;Ⅲ期:(37.37±4.21) mm与(36.34±4.70) mm;Ⅳ期:(31.77±6.05) mm与(30.59±6.11) mm],但差异均无统计学意义(P均＞0.05). 结论 宫颈长度于妊娠28周后逐渐缩短,孕期常规超声检查时行序贯宫颈长度测量对预测早产可能有益.     

胎儿Dandy-Walker综合征6例分析及文献复习

目的：探讨胎儿Dandy-Walker综合征的超声影像学特征、诊断及处理。方法：总结6例胎儿Dandy-Walker综合征病例,复习有关文献,讨论胎儿Dandy-Walker综合征的超声影像学特征、诊断及处理。结果：6例患者中有3例于妊娠中期超声检查发现胎儿Dandy-Walker综合征,经羊膜腔穿刺胎儿核型分析发现染色体异常后引产,另3例于妊娠晚期超声发现胎儿Dandy-Walker综合征,1例引产,2例分娩后CT检查未发现明显异常。结论：掌握胎儿Dandy-Walker综合征的超声影像学特征,早期识别,及时产前诊断,正确处理,对降低Dandy-Walker综合征胎儿出生率至关重要。     

分娩时脐动脉血气分析的临床意义

目的了解分娩时脐动脉血气的临床意义。方法选取2005年3月至2006年12月在北京大学第一医院分娩的产妇810例,临床诊断胎儿窘迫401例,无胎儿窘迫409例,在胎儿娩出后立即行脐动脉血气分析,并追踪新生儿结局,进行分析。结果①胎儿窘迫组中脐血pH值〈7.2者49例,占12.2%,而无胎儿窘迫组pH值〈7.2者26例,占6.4%。二者间差异有统计学意义（P=0.004）;胎儿窘迫组脐血pH均值（7.25±0.24）,无胎儿窘迫组脐血pH均值（7.28±0.05）,两组差异有统计学意义（P=0.023）;②新生儿出生后1min Apgar评分〉7分者中脐血pH值〈7.2占8.3%,而Apgar评分≤7分者中高达34.5%,二者差异有统计学意义（P=0.000）;③本研究中新生儿缺氧缺血性脑病（HIE）共18例,Apgar评分≤7分对HIE诊断的敏感性为38.9%,特异性为97.2%,阳性预测值24.1%,阴性预测值98.6%;脐血pH值〈7.2对HIE诊断的敏感性55.6%,特异性91.8%,阳性预测值13.3%,阴性预测值98.9%;Apgar评分≤7分和pH值〈7.2联合预测HIE的发生,特异性能增加至99.4%,阳性预测值增加至50%,阴性预测值98.4%。结论临床诊断胎儿窘迫者大多数出生时脐血气正常,可能存在过度诊断和治疗现象;血气分析是Apgar评分的补充,二者结合能增加对HIE诊断的特异性和阳性预测值,应结合Apgar评分和脐动脉血气分析来共同评价新生儿预后。     

产前诊断先天腹壁缺损的早期外科治疗

先天性腹壁缺损在新生儿并不少见，常常需要早期手术治疗。这类疾病包括脐膨出、腹裂、膈疝等，尽早手术治疗对预后有重要意义。随着产前诊断技术的发展，这些疾病多在孕中晚期得到诊断。我科自2003年6月至2005年10月共收治产前诊断的先天性腹壁缺损10例，分析报道如下。     

阴道分泌物胎儿纤维连接蛋白与宫颈长度联合预测早产的多中心前瞻性研究

Objective To discuss the clinical value of fetal fibronectin (fFN) and cervical length in predicting preterm birth. Methods Totally, 511 pregnant women at 22-35 weeks of gestations were enrolled from Dec. 2006 to Dec. 2007 at 4 tertiary hospitals in Beijing, and all with either symptoms or high risk factors of preterm birth, but without preterm premature rupture of membrane or vaginal bleeding. Cervical fFN were determined and cervical length of each subjects were measured by ultrasound. The pregnancy outcomes were compared. Results The sensitivity, specificity and negative predictive value (NPV) of fFN in predicting preterm birth within 7 d were 77.4%, 69.4% and 97. 9%, respectively; and 70.5%, 70.0% and 96.2% for deliveries within 34 weeks. The above figures changed to 54.8%, 66.3%, 95.8% for deliveries within 7 d and 59.1%, 67.2%, 94.6% for those within 34 weeks, respectively, when cervical length ≤3 cm was applied to predict preterm birth. When fFN and cervical length were combined, the sensitivity, specificity and NPV were 51.6%, 87.1%, 96.5% for deliveries within 7 d, and 45.5%, 87.60/00, 94.5% for those within 34 weeks, respectively. Conclusions FFN has higher NPV and specificity than cervical length in predicting preterm birth within 7 d and 34 weeks, and the positive predictive value and specificity can be improved when combined with cervical length.     

17α-羟基孕酮己酸酯和醋酸甲羟孕酮预防孕鼠感染性早产的机制

目的 通过研究17α-羟基孕酮己酸酯(17α-hydroxyprogesterone caproate,17P)和醋酸甲羟孕酮(medroxyprogesterone acetate,MPA)对早产小鼠子宫肌层及胎盘组织环氧合酶-2(cyclooxygenase-2,COX-2)和肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)表达的影响,探讨孕激素预防感染性早产的作用机制.方法 选择清洁级雌性CD-1小鼠30只,于妊娠第15天,随机分为对照组、内毒素脂多糖( lipopolysaccharides,LPS)组、17P 1 mg+LPS组、17P 2 mg+LPS组、MPA 1 mg+ LPS组、二甲基亚砜(dimethyl sulfoxide,DMSO)+ LPS组,每组5只.治疗组均于皮下注射相应剂量的孕激素1h后腹腔注射LPS,6h后取小鼠子宫肌层及胎盘组织,用实时荧光定量聚合酶链反应技术和免疫组织化学方法检测子宫肌层及胎盘组织COX-2和TNF-α mRNA及蛋白的表达.采用ANOVA进行统计学分析,两两比较用LSD法.结果 1.各组小鼠子宫肌层及胎盘组织中COX-2 mRNA和TNF-α mRNA的相对表达量的比较:(1)各给药组孕鼠子宫肌层及胎盘组织COX-2mRNA和TNF-α mRNA表达均显著高于对照组(P＜0.05).(2)17P 1 mg+LPS组、17P 2 mg+LPS组和MPA 1 mg+LPS组小鼠子宫肌层COX-2 mRNA表达分别为11.410±3.931、8.352±3.209和11.920±2.905,均显著低于LPS组(20.540±4.147)和DMSO组+LPS组(18.620±4.156) (P＜0.05),而TNF-α mRNA也低于LPS组和DMSO组+LPS组,但差异无统计学意义(P＞0.05).(3)17P 1 mg+LPS组、17P 2 mg+LPS组、MPA 1 mg+LPS组胎盘组织COX-2 mRNA表达分别为10.864±3.777、7.084±1.667和11.830±3.652,均显著低于LPS组(18.920±4.106)和DMSO组+LPS组(23.820±7.554) (P＜0.05).(4)17P 1 mg+LPS组、17P 2 mg+LPS组、MPA1 mg+ LPS组胎盘组织TNF-α mRNA表达分别为14.340±1.618、11.488±2.910和13.040±2.982,均显著低于LPS组(24.240±7.059)和DMSO组+LPS组(23.040±5.896)(P＜0.05).2.各组小鼠胎盘组织COX-2和TNF-α蛋白表达的比较:(1)各给药组胎盘组织中COX-2蛋白的表达和TNF-α蛋白的表达明显高于对照组(P＜0.05).(2)17P 1 mg+LPS组、17P 2 mg+LPS组和MPA1 mg+ LPS组COX-2蛋白的表达分别为14360.92±1766.01、13340.18±965.35、12870.81±1521.97,明显低于LPS组(16426.64±1823.87)和DMSO组+LPS组(16761.23±2388.17)(P＜0.05);但3个治疗组之间差异无统计学意义(P＞0.05).(3) 17P 1 mg+LPS组、17P 2 mg+LPS组、MPA 1 mg+ LPS组TNF-α蛋白的表达分别为22 750.96±4656.68、22 766.24±3500.34和20 770.01±3318.48,显著低于LPS组(26204.49±5090.34)和DMSO组+LPS组(27 346.18±3269.30)(P＜0.05),而3组之间差异无统计学意义(P＞0.05).结论 17P和MPA对感染性早产小鼠子宫和胎盘组织COX-2及胎盘中TNF-α的表达有抑制作用,可能是其预防早产的机制之一.     

妊娠中期羊膜腔絮状物的意义

妊娠中期超声检查所提示的羊膜腔絮状物(AFS)是一种高回声物质, 是宫内感染发生炎性反应后, 由于重力作用沉积于子宫颈内口处的聚集性现象。AFS往往提示羊膜腔内感染, 与晚期流产、早产关系密切。一旦出现AFS合并子宫颈管缩短, 应行羊膜腔穿刺术明确感染性质, 同时可积极行抗炎治疗, 定期超声监测子宫颈长度以及AFS的变化情况。本文综述AFS的性质、在晚期流产和早产中的意义、抗生素治疗的有效性, 从而为妊娠中期超声检查提示AFS孕妇的治疗以及管理提供新的临床思路。